American Gastroenterological Association - Advancing the Science and Practice of Gastroenterology

News from the Literature | Practice | Research | Education & Meetings | Announcements | Policy Update | Journals & Publications

LEADING THE NEWS

AGA No Longer Recommends Watchful Waiting for Some High-Risk Barrett’s Patients

Endoscopic removal of pre-cancerous cells in patients with confirmed, high-risk Barrett’s esophagus is recommended rather than surveillance, according to a new AGA “Medical Position Statement on the Management of Barrett’s Esophagus” published in Gastroenterology. 

NEWS FROM THE LITERATURE

Smoking Is Independent Risk Factor for Idiopathic CP

Alcohol has been implicated in the development of chronic pancreatitis in 60 to 90 percent of patients, although percentages in the U.S. are unknown. The frequency of alcohol-related chronic pancreatitis at tertiary U.S. referral centers is lower than expected, according to a study in Clinical Gastroenterology and Hepatology. Idiopathic chronic pancreatitis and non-alcohol etiologies represent a large subgroup, particularly among women. Smoking is an independent risk factor for idiopathic chronic pancreatitis.

Clinical Gastroenterology and Hepatology; 2011: 9(3): 266-273

Nondysplastic Barrett's Patients Have Low Risks for Developing Dysplasia

The risks of dysplasia and esophageal adenocarcinoma are not clear for patients with nondysplastic Barrett's esophagus. The rate of progression has been overestimated in previous studies. Data published in Clinical Gastroenterology and Hepatology suggest that there is a lower incidence of dysplasia and esophageal adenocarcinoma among patients with nondysplastic Barrett's esophagus than previously reported. Because most patients are cancer free after a long-term follow-up period, surveillance intervals might be lengthened, especially for patients with shorter segments of Barrett's esophagus.

Clinical Gastroenterology and Hepatology; 2011: 9(3) 220-227

Rapid Improvement After Treatment with Gluten-Free Diet

Celiac disease patients often complain of symptoms consistent with GERD. In a study appearing in Clinical Gastroenterology and Hepatology, doctors concluded that GERD symptoms are common in classically symptomatic untreated Crohn's disease patients. The gluten-free diet is associated with a rapid and persistent improvement in reflux symptoms that resembles the healthy population.

Clinical Gastroenterology and Hepatology; 2011: 9(3): 214-219

Lymph Nodes May Be Used As Sites for Hepatocyte Transplantation

Hepatocyte transplantation is a potential therapeutic approach for liver disease. However, most patients with chronic hepatic damage have cirrhosis and fibrosis, which limit the potential for cell-based therapy of the liver. The development of an ectopic liver as an additional site of hepatic function represents a new approach for patients with end-stage liver disease. According to a study in Gastroenterology, functional ectopic liver tissue in lymph nodes rescues mice from lethal hepatic disease; therefore, lymph nodes might be used as sites for hepatocyte transplantation.

Gastroenterology; 2011: 140(2): 656-666.e2

PRACTICE

CGH Image of the Month

Small-Bowel Adenocarcinoma
Ivan Jovanovic, Lucia C. Fry, Klaus Mönkemüller

A 63-year-old man with coronary artery disease and hypertension was admitted to a hospital because of progressive shortness of breath and chest pain. The patient had several episodes of melena starting 24 hours before presentation. On clinical examination, the patient was pale. His hemoglobin level was 7.5 g/L with a hematocrit of 24 percent. The remaining laboratory parameters were within reference ranges. Esophagogastroduodenoscopy and colonoscopy were unremarkable. An oral double-balloon enteroscopy disclosed a circumferential, partially stenosing, jejunal tumor 80 cm distal to the pylorus. During surgery, a partially obstructing mass was found (figure).

Read more in Clinical Gastroenterology and Hepatology.

AGA Responds to Medicare Advantage Plan Updates

The AGA submitted comments to CMS concerning proposed language in its update of Chapter 4 of the Medicare managed care manual, Benefits and Beneficiary Protections, that would allow Medicare Advantage plans to restrict access to certain manufacturers' drugs and durable medical equipment (DME) starting in 2012.

We indicated that nowhere in Chapter 4 does the manual clearly specify what criteria or methodology CMS plans to use when establishing coverage policies that can potentially restrict access to services, pharmaceuticals, medical devices and supplies for beneficiaries, and how plans will determine which drugs and/or DME items are covered. We were concerned that CMS’ open-ended proposal could restrict needed care by allowing managed care plans to cut off coverage of important treatments currently available to beneficiaries who choose a Medicare Advantage plan.

The AGA stated that there needs to be a requirement that the Medicare Advantage plans have a clear process and standards in place for establishing drug formularies and making utilization management and medical necessity determinations for beneficiaries. The plans should use multi-stakeholder and multi-disciplinary committees to evaluate pharmacy benefits, which should include physicians in the appropriate specialty who treat such patients.

We recommended that CMS revise the manual to add a section that clearly delineates the process that Medicare Advantage plans should use to determine appropriate access to drugs and DME items for beneficiaries. We also recommend that CMS clearly define the mechanism for an appeals process, which would allow beneficiaries access to medically necessary drugs, DME and treatments based on their individual circumstances.

Carriers Should Not Reject New PT Modifier

As announced in the Jan. 6 issue of AGA eDigest, CMS issued an MLN Matters article, which provides guidance on the extension of waiver of deductible to services furnished in connection with or in relation to a colorectal screening test that becomes diagnostic or therapeutic.

Effective Jan. 1, 2011, the Affordable Care Act waives the Part B deductible for colorectal cancer screening tests (codes G0104, G0105, G0106 and G0121) that become diagnostic.

At this time, carriers should be properly reimbursing GI facilities that use the new PT modifier to bill for Medicare-covered colonoscopies that start out as screening procedures but end up as diagnostic procedures due to the finding of a polyp or some other clinical indication.

When a Medicare beneficiary presents for a covered screening colonoscopy, Medicare will pay the full provider and facility fee. If the screening colonoscopy ends up as a diagnostic colonoscopy instead, then Medicare would still honor the waiver of the patient's deductible, but not the waiver of the co-pay, and the claim needs to be submitted with the new PT modifier.

Ambulatory surgery centers across the country have reported that regional carriers were rejecting claims billed with the PT modifier with a variety of denial explanations. CMS is issuing private clarifications and instructions directly to the carriers to correct the claims processing errors. If you are experiencing claims denials of the PT modifier, please contact Anne Marie Bicha at the AGA: abicha@gastro.org.

CMS to Begin Reprocessing Retroactive Adjustments

CMS soon will begin reprocessing Medicare claims affected by retroactive provisions of the Patient Protection and Affordable Care Act and physician fee schedule legislation. These include claims for physicians, hospitals and other care providers affected by payment adjustments retroactive to Oct. 1, 2009, Jan. 1, 2010, and April 1, 2010.

Reprocessing likely will start with inpatient claims, which are expected to have the fewest affected claims, then outpatient claims followed by physician claims. In most cases, the Medicare claims administration contractor will automatically reprocess a provider’s retroactive adjustments. However, providers will need to request a manual reopening/adjustment from their Medicare contractor for any claims with submitted charges lower than the revised 2010 physician fee schedule amount.

For more information, see the CMS notice.

Reimbursement and Coding for GI — Upcoming Seminars

Sponsored by the AGA Institute and McVey Associates, these one-day seminars will provide participants with the most current International Classification of Diseases-9 and current procedural terminology coding instruction, including 2011 changes, as well as strategies for correct coding, reimbursement and compliance for gastroenterology.

Upcoming 2011 Dates

• March 2: LaGuardia, NY (rescheduled from Jan. 21)
• March 9: Herndon, VA
• March 9: Syracuse, NY
• March 18: Atlanta, GA
• April 6: Houston, TX (advanced)
• April 12: Parsippany, NJ
• April 12: Cleveland, OH
• April 19: Philadelphia, PA
• April 20: Pittsburgh, PA
• April 26: Hartford,CT
• May 24: Somerset, NJ

Learn more and register.

Coding Cruise: March 27–April 3
Enjoy a seven-day Caribbean cruise while learning the latest coding, billing and reimbursement information for GI practices. Learn more.

RESEARCH

Your AGA Research Foundation Gifts Support ...

... Andrew Rhim, MD, of the University of Pennsylvania School of Medicine who received the AGA Fellowship to Faculty Transition Award in 2009.

“I would like to express my sincere gratitude to the AGA and the foundation for honoring me with this generous award. While a gastroenterology fellow at the University of Pennsylvania, I initiated my own research program studying the molecular and functional differences among cells that make up a pancreatic tumor. Specifically, I am interested in defining what molecular events are necessary to allow some cancer cells to metastasize. With the outstanding mentorship of Ben Stanger, MD, PhD, I have developed a unique mouse model of pancreatic cancer that will help address this issue, which has previously been difficult to study. My hope is that my research will lead to earlier diagnosis of pancreatic cancer, as well as better treatment for this deadly disease. With the aid of the award, I look forward to achieving my goals and becoming an active and contributing member of the AGA.”

To make a donation, visit www.gastro.org/contribute.

Funding Available for Esophageal Disease Research

The June & Donald O. Castell, MD, Esophageal Clinical Research Award, available through the AGA Research Foundation, provides $35,000 for research/salary support to young investigators interested in esophageal disease research.

The award will support young faculty (not fellows) who have demonstrated exceptional promise and have some record of accomplishment in research. To be eligible for the award, candidates must:

• Hold an MD, PhD or equivalent degree and a full-time faculty position at a North American institution by July 1, 2011.
• Be AGA members at the time of application submission.
• Be in the beginning years of their careers; no more than seven years shall have elapsed following the completion of clinical training or PhD.
• Devote at least 50 percent of their efforts to research related to esophageal function or diseases.

The application deadline is April 1, 2011. For more information and to apply, visit the AGA website.

More Funding Opportunities
Application deadlines are approaching for a variety of travel grants to DDW® 2011 and student awards. View a complete list of awards and deadlines.

EDUCATION & MEETINGS

DDSEP^® 6 Addresses Emerging Topics

AGA Institute’s Digestive Diseases Self-Education Program^® (DDSEP) has expanded its reach with content on two topics gaining increasing popularity within the field: GI health in women, and nutrition, obesity and eating disorders.

Health care is utilized by women at a higher rate than men in the U.S., making it essential for GI clinicians to keep current on the many GI disorders that have specific implications for women, including functional bowel disorders, gallstones and autoimmune liver disease. DDSEP’s entirely new chapter, Digestive Health and Disease in Women, includes information on:

• Differences in gender-based biology.
• Effects of hormones on the GI tract.
• Presentation and management of GI and hepatobiliary diseases in women.
• Effect of pregnancy on the presentation and course of GI and hepatobiliary diseases.
• Overall effect of gender differences in GI and liver patients.

DDSEP’s chapter on nutrition, obesity and eating disorders features more robust content on the individual and societal impacts of obesity and eating disorders, helping GIs better identify inadequate nutrition and the role it plays in both obesity and eating disorders. Updated information in this chapter includes:

• Various techniques of nutritional assessment and their limitations.
• Dietary and nutritional management of specific digestive disorders.
• Common eating disorders with emphasis on the GI and nutritional implications.
• Pathophysiology and treatment of obesity and the role of the GI tract in energy metabolism.
• Macro and micronutrients and symptoms and signs of deficiency states.

Owing its success to an intense peer review process that ensures the end product is current and up to date, DDSEP continues its run as the field’s most comprehensive review of gastroenterology, hepatology and nutrition.

Order your copy today.

ANNOUNCEMENTS

Low Magnesium Levels Associated with PPI Long-Term Use

The FDA announced that prescription PPI drugs may cause low serum magnesium levels if taken for prolonged periods of time. Low serum magnesium levels can result in serious adverse events, including muscle spasm, irregular heartbeat and convulsions; however, patients do not always have these symptoms. In approximately one-quarter of the cases reviewed, magnesium supplementation alone did not improve low serum magnesium levels and the PPI had to be discontinued.

Health-care professionals should consider obtaining serum magnesium levels prior to initiation of prescription PPI treatment in patients expected to be on these drugs for long periods of time, as well as patients who take PPIs with medications such as digoxin (a heart medicine), diuretics or drugs that may cause hypomagnesemia. For patients taking digoxin, this is especially important because low magnesium can increase the likelihood of serious side effects. Health-care professionals should consider obtaining magnesium levels periodically in these patients.

Read the full safety alert, including drug safety communication.

AGA Submits Comments on Meaningful Use

On Feb. 25, the AGA, in conjunction with our sister societies, submitted comments on the Health Information Technology (HIT) Policy Committee’s preliminary recommendations on Stages 2 and 3 objectives for electronic health record (EHR) meaningful use; we submitted detailed comments to CMS in March 2010 on the Stage 1 requirements. The AGA also signed on to letters from the Alliance of Specialty Medicine and the AMA on this issue.

We stated that many physicians are struggling to meet Stage 1 objectives, making it premature to offer Stage 2 recommendations. Our members are still navigating the risks associated with purchasing certified EHR systems, overhauling their practices to incorporate meaningful use reporting requirements, coping with the decision that ambulatory surgery centers are not approved sites for meaningful use incentives, and deciding whether efforts to meaningfully use EHRs will actually cost more than the $44,000 in incentive payments that are allowed over the life of the meaningful use incentive program.

We note that the proposed Stage 2 recommendations are not onerous if a physician has already complied with or has been successful in meeting Stage 1 requirements. However, the Stage 2 requirements are extremely difficult, if not impossible, to meet if a physician has been unsuccessful in Stage 1. Inflexible, overly ambitious incentive program requirements will only hinder HIT transitions underway today. In addition, the Stage 2 requirements may be too burdensome for many health-care providers to meet, especially smaller physician practices that already may lag behind in adoption of HIT.

The HIT committee will review all comments and provide this information to CMS to assist them in future rulemaking on meaningful criteria for Stages 2 and 3.

Help Raise $50,000 to Fight Colon Cancer

March is Colorectal Cancer Awareness Month. Encourage your patients and those at risk to commit to being screened for colon cancer. For each screening commitment, Olympus America Inc. will donate $1 (up to $50,000 total) to two leading colon cancer advocacy groups: the Colorectal Cancer Coalition and Colon Cancer Alliance.

Visit FinditFirst.com and select one of the links to commit to be screened or to commit to convincing a friend, family member or patient to get screened.

POLICY UPDATE

House Repeals 1099 Provision

The House of Representatives passed H.R. 4, the Small Business Paperwork Mandate Elimination Act, by a vote of 314-112. This act repeals the 1099 provision in the Patient Protection and Affordable Health Care Act, which requires businesses to file a 1099 tax form for every transaction of $600 or more.

The AGA supports repeal of the 1099 provision since it places undue paperwork burdens on physician practices, especially in light of all of the other regulatory requirements with which they need to comply.

The Senate also approved a measure that would repeal the 1099 provision, but included different offsets to pay for the repeal. The House and Senate will need to come to an agreement on how to pay for the repeal and that agreement would need to pass both chambers. Read more in the AGA Washington Insider, a policy blog for GIs.

Passage of New Preventive Screening Legislation Stalled

Passage of laws requiring insurance providers to cover the costs of colon cancer screenings has stalled over the past two years and advocates are bracing to protect existing legislation in states that currently guarantee access to these lifesaving tests. The progress made in passing state-mandated coverage of colon cancer screening tests according to accepted medical guidelines has come to a near halt as state legislatures reconsider their role in the wake of the passage of the Patient Protection and Affordable Care Act .

Only one state, Hawaii, passed coverage legislation in 2010. Combined with Vermont’s legislation passed in 2009, only two states have improved their grade in the past two years as reported by the annual Colorectal Cancer Legislation Report Card — the slowest improvement since the report card launched seven years ago. With the addition of Hawaii in 2010, 23 states and the District of Columbia now require insurance coverage of colonoscopies and other procedures that follow accepted medical guidelines, earning them the grade of A. Ten other states require varying degrees of coverage, with scores of B, C or D, while 17 states score an F for failing to mandate any coverage of the cost of colon cancer screening. Learn more.

AGA has participated in the Colorectal Cancer Legislation Report Card since it was launched in 2004.

JOURNALS & PUBLICATIONS

Call for Papers on Clinical Trials: Gastroenterology

Gastroenterology is committed to advancing clinical practice in the field of digestive disease. Recognizing that clinical trials generally have the greatest impact of all studies on clinical practice, Editor Anil K. Rustgi, MD, and his associate editors strongly encourage authors to submit their manuscripts on clinical trials (diagnostic validation, therapeutic efficacy) of drugs, biological materials and devices in digestive, liver and pancreatic diseases, including studies at Phases I, II and especially III, to Gastroenterology for consideration. The journal is also interested in publishing trials in endoscopic and imaging modalities.

There are several important reasons to submit clinical trial research for publication in Gastroenterology:

• With an impact factor of 12.9, Gastroenterology is the premier journal in the field.
• Gastroenterology is the journal that will directly reach the largest portion of physicians who care for and make treatment decisions for patients with GI or liver disease.
• Authors who submit their manuscripts to Gastroenterology typically will receive decisions within three weeks or fewer.
• Accepted manuscripts will be published online and indexed on PubMed within 10 days of acceptance.

To submit your manuscript to Gastroenterology, go to www.editorialmanager.com/gastro.

For important information on how to report clinical trials, go to www.gastrojournal.org/authorinfo. To review the current and past issues of the journal, go to www.gastrojournal.org.